Provider Demographics
NPI:1568643187
Name:LEE, MAYRA IVELISSE (RN)
Entity Type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:IVELISSE
Last Name:LEE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:MAYRA
Other - Middle Name:IVELISSE
Other - Last Name:LATORRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:385 TREMONT AVE
Mailing Address - Street 2:111 I D
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-1023
Mailing Address - Country:US
Mailing Address - Phone:973-676-1000
Mailing Address - Fax:973-395-7084
Practice Address - Street 1:385 TREMONT AVE
Practice Address - Street 2:111 I D
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1023
Practice Address - Country:US
Practice Address - Phone:973-676-1000
Practice Address - Fax:973-395-7084
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR017150171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator